SpaMedica Exeter

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff recognised and reported incidents and near misses in line with their policy. They did this using the online incident reporting system which notified leaders. They provided examples of incidents raised. We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence.

Managers investigated incidents and shared lessons learned with the whole team and the wider service. The hospital manager had completed training in investigating patient safety incidents. Managers ensured actions from patient safety alerts were addressed and progress was monitored. Incidents were monitored at a national and local level; all were discussed at monthly hospital meetings among the team. Staff were informed of incidents and learning through monthly cascade team meetings.

Staff were able to identify and report risks, secure in the knowledge these would be addressed. During the last 12 months prior to the assessment, 46 incidents were reported, none were moderate harm or above, with most recorded as no physical harm. This reported level was in line with the organisational reporting average. Staff were encouraged to report all incidents by management and staff felt safe and supported to report.

Staff were clear of the duty of candour and when things went wrong would apologise and be open and transparent. There was a provider level Duty of Candour (DOC) policy, and this could be accessed by all staff.

Safety bulletins from national safety organisations, such as the Medicines and Healthcare products Regulatory Agency (MHRA) were shared with all staff within the wider organisation. This was through electronic safety updates and shared with staff at team meetings. An example shared was regarding a recent recall of a specific consumable piece of equipment used.

During 2025, SpaMedica Exeter worked closely with the local integrated care board (ICB) following a patient complaint. The ICB commission NHS work for the provider with key performance indicators to meet. Learning from this event was identified and included actions which were promptly actioned. The hospital manager spoke of the clear referral pathways they now have as one of the positive learning actions from this event.

The evidence showed good standard. The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had a referral and admission process. This ensured all essential information about the patient was received to determine if the patient’s needs could safely be met.

There was an admission criterion for both NHS and private patients. These criteria set out where they had limitations in services and minimised risks by appropriately excluding some patients. At the time of our assessment, most patients receiving treatment were NHS funded. The service received referrals from a range of ophthalmic providers and patients’ own GPs.

Referrals were received at head office and appointments made by head office for pre-assessment if the patient was suitable. Once patients had their pre-assessment at SpaMedica Exeter, the patient co-ordinator would book the theatre day. Follow up appointments post operatively were also arranged. Patient’s operations were cancelled if it was not safe to complete their procedure, for example if there was a reduction in staffing against planned numbers or if the patient became unwell.

Safety and continuity of care was a priority throughout people’s care pathway. Patients were assessed prior to surgery and findings considered when planning care and treatment.

There were systems and processes to ensure the correct patients were treated throughout the patient journey. We tracked the patient journey and patient care from pre- assessment, admission, operating theatre and to recovery. We observed handover of patient information including all related identification checking processes. Once in theatre, the World Health Organisation (WHO) surgical safety check list was used to avoid harm and improve team communication. We observed safety checks being carried out before and during surgery. We reviewed 5 sets of patient records and found the WHO checklist completed correctly.

Patient records were a mixture of electronic, and paper based and were kept securely.

The provider operated a support line for patients to contact if they had additional questions or post treatment. This was available 24 hours a day and advice was provided by ophthalmic clinicians.

As a result of a recent patient safety incident, referral pathways were improved with the local NHS provider, and they now have quarterly meetings to discuss.

The evidence showed a good standard. The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve it. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The service had up-to-date policies and procedures to keep people safe from abuse or improper treatment. Staff followed processes to report concerns. Staff had access to the policy, available online. There were safeguarding pathways on display in all areas clearly instructing staff on how to raise safeguarding concerns.

Staff understood how to protect patients from abuse. Staff were clear on the processes to follow if they had a safeguarding concern and provided examples of safeguarding concern’s they had raised. We reviewed training, all staff were Level 2 trained in safeguarding, the manager was Level 3. The safeguarding lead was Level 4 trained and supported staff in escalating concerns.

Patients were supported to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 and their rights under the Equality Act 2010. Staff understood the importance of supporting equality and diversity and ensured care and treatment was in accordance with the Act.

The hospital had a defined recruitment pathway and procedures to help ensure the relevant recruitment checks had been completed for all staff. These included a disclosure and barring service (DBS) check, occupational health clearance, references, qualification and professional registration checks. We looked at 5 staff records and found these were all complete.

The evidence showed a good standard. The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service worked with patients to understand and manage risks. Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them. Staff spoke about their role in removing barriers to care by ensuring they could support all patients.

There was a balanced and proportionate approach to risk to support patients and respect the choices they made about their care. Risk assessments about care were person centred, proportionate and regularly reviewed with the person, where possible.

Patients had all treatment under local anaesthetic; the provider did not use general anaesthesia. Staff worked closely with other clinicians, including opticians and GPs to ensure they understood the patient risks. Patients were informed about any risks and how to keep themselves safe. The patients we spoke with stated they were involved in their care and treatment, and the staff had explained the risks involved with their treatment. We saw risk assessments had been completed by staff to highlight concerns and record health information such as blood pressure, past medical history and allergies.

The staff completed a team brief with all the staff at the beginning of each shift followed by a team brief in theatre. We observed a theatre brief where staff allocation and the theatre list was discussed in detail.

The service took risks to patients seriously and ensured patients who had surgery were safe. We followed 5 patient journeys from admission to discharge and saw safety checks were completed diligently, and patient risks were checked multiple times.

There were sepsis posters around the hospital to alert staff and patients to the signs and symptoms of sepsis.

Staff responded promptly to any sudden deterioration in a patient’s health. There was an escalation policy directing staff to call 999 to transfer patients to an acute NHS hospital. A resuscitation trolley was available; this was regularly checked by staff. Review of audit record was undertaken all expiry dates of items were listed and those expiring soon were highlighted. A ‘grab bag’ was also available and a record of checks undertaken was reviewed which demonstrated that the contents was regularly checked.

The evidence showed a good standard. The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Facilities, premises and equipment were purpose-built and used to meet the needs of all patients who used the service. The building was modern, and the service was located on the ground floor. The admission area, theatres and recovery area were designed to allow transfer between the different areas.

The service was fully aware of all potential risks in the care environment and controlled them well. Staff made sure equipment, facilities and technology supported the delivery of safe care.

The building was bright, spacious and clean with sufficient ventilation and heating. The open waiting area had sufficient seating. There was CCTV which was monitored from the main reception desk. A couple of patients commented to us about the spacious free parking directly outside.

There was a comprehensive system to proactively manage the safety, maintenance and repair of facilities, premises and equipment. Back-up generators were available in the event of a power failure. Leaders maintained oversight of equipment to ensure it was safe and ready to use. We checked a range of items and found them all to have been recently serviced. Equipment audits were completed and outcomes shared with staff. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

There was a site risk register in line with the Risk Management Policy which was reviewed monthly. A general site/environmental risk assessment was recently completed. There was a named laser protection advisor and laser safety audits were regularly conducted. There was a laminated sign used when the laser was being operated. A laser safety maintenance report was reviewed, which showed no concerns.

Stock was in a secure area and stored off the floor. Record of stock rotation was completed monthly, and we checked a range of consumable items. We did find an item out of date and highlighted this to the hospital manager; other items reviewed were all in date.

Staff disposed of clinical waste safely and used appropriate systems for the management of sharps. We did find one sharps bin not dated which was highlighted to staff. There was a contract for the collection of clinical waste which was collected weekly.

The evidence showed a good standard. The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development opportunities. Staff worked together well to provide safe care that met patients’ individual needs.

The service ensured they had enough staff to keep patients safe. Staff members included a hospital manager, registered nurses, healthcare technicians, patient coordinator, and optometrists. The service employed permanent and bank staff. There had been a 22% turnover in staff, some due to the travel, others for career progression as well as personal reasons. Bank usage was mostly to cover the optometrist.

The service employed permanent staff who moved between other SpaMedica services in the wider regions to support safe staffing levels. Staff told us they understood this was a necessary requirement to maintain patient safety, though some staff said there had been a lot of travelling sometimes at quite a distance.

Some of the staff we spoke with raised concerns regarding staffing levels. We spoke with the leadership team who were assured staffing levels were safe and aligned with their Clinical Safer Staffing Levels Standard Operating Procedure. We reviewed this policy and saw it outlined clear staffing levels and drew standards from Association for Perioperative Practice (AfPP) and Royal College of Ophthalmologist.

Safer recruitment processes were followed to make sure all staff were suitably experienced, competent and able to carry out their role; we reviewed 5 staff files and found no concerns. All staff had an induction, and staff were provided with supervision as standard. Staff received the support they needed to deliver safe care. This included supervision, appraisal and support to develop, and where needed, professional revalidation. Appraisals were completed in line with their Employee Appraisal Policy and included a mid-year progress review. All staff had their last appraisal completed in April 2025.

All staff competencies were aligned to ensure only allocated staff to clinics based on their competency. Nursing and healthcare technician staff completed competencies every 3 years. We saw evidence competencies had been signed off. Staff told us they were reminded if competencies or mandatory training was due to expire.

Staff received training relevant to their role and had access to mandatory training, which included online and face to face learning. There were though some gaps in staff compliance. The provider was assured any outstanding practical training needs were escalated.

The evidence showed a good standard. The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas within the service were visibly clean, hard furnishings were well-maintained and easy to clean. We noted a small amount of dust on the resuscitation trolley, and this was promptly cleaned. Patients were protected as much as possible from infection risks as the premises and equipment were kept clean and hygienic throughout. There was a systematic approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. Patients we spoke with all commented how clean the premises were. SpaMedica Exeter had been awarded the 5-star cleanliness rating in 2025.

Staff completed daily cleaning check lists to record compliance with cleaning schedules and standards. Regular clinical audits were completed on a rolling programme. We reviewed 3 months of clinical audits and found them to be comprehensive and complete.

Staff followed infection control principles including the use of personal protective equipment (PPE). Staff had infection prevention training, though not all staff were fully compliant at the time of assessment. Hand-washing and sanitising facilities were available for staff and visitors throughout, and we observed staff practising effective hand hygiene. Adequate supplies of PPE were available. Staff were observed wiping down equipment after patient contact and between patients. There were multiple large pieces of equipment in the operating room and these were kept clean, well maintained and dust free.

Staff followed protocols regarding decontamination, reusables were managed well and then instruments were sent to an external contractor for sterilisation. Where staff used single-use equipment for minor surgery, they documented serial numbers in patient records. This meant items were fully traceable in line with national guidance.

The evidence showed a good standard. The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff followed good practice in medicines management and in line with national guidance. The service always made sure medicines and treatments were safe and met patients’ needs, capacities and preferences.

Staff followed systems and processes to prescribe and administer medicines safely. Only staff who had completed competencies in the management of medicines dispensed and administered medicines to patients. Staff compliance for medication management was 94%. Patients’ medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence. Medication records were paper based, but information was also recorded on an electronic system.

Patients were appropriately involved in decisions about their medicines. Patients were involved with assessments and reviews about the level of support they needed to manage their medicines safely and to make sure their preferences were considered. Allergies were clearly recorded.

Medication was all securely stored and restricted to appropriate staff. The service had medication stored in a temperature-controlled room. Those medicines which required refrigeration were stored in fridges and the temperatures were monitored daily and within normal limits, medical gases onsite were stored safely and securely.